Northeast Georgia Health System-posted 3 months ago
Full-time
Gainesville, GA
5,001-10,000 employees
Hospitals

The Case Management Social Worker is responsible for the provision of medical social work services to patients receiving care in the hospital setting. Assesses the social, psychological, cultural, environmental, and financial situation, as well as disposition needs for each referred patient. Collaborates with RN Case Manager, patients, families, healthcare team members, and community agencies to develop and implement plans to address identified needs. Evaluates effectiveness of plans and initiates change as needed. Uses crisis intervention, problem solving model, community organization, and advocacy skills in identifying needs and resources in the hospital and community. This position will come in contact with patients in the neonate, infant, child, adolescent, adult, and geriatric age groups; Employees will perform clinical duties in accordance with population specific guidelines and adhere to National Patient Safety Guidelines. Provides cross coverage for all Social Workers as required across all settings in the care continuum, including weekend rotation (as needed).

  • Uses a family systems theory framework to gather information, to include, patient's social, psychological, cultural, environmental and financial situation.
  • Identifies legal, financial, social, educational, and environmental factors which may affect medical care and/or discharge plans.
  • Informs team members of critical information that will affect patient's stay while in the hospital and/or discharge plan.
  • Assesses and assures appropriate reporting of any potential/actual abusive relationship, such as child/adult abuse, neglect or domestic violence.
  • Assesses upon request psychiatric/substance abuse disorders and initiates or assists in arranging appropriate intervention and referrals for treatment upon discharge.
  • Uses SBIRT techniques to identify patients who use alcohol and other drugs at risky levels.
  • Expedites the discharge plan through excellent networking and team skills within the patient's expected length of stay per working DRG.
  • Provides patient advocacy and ensures patient's Freedom of Choice and Medicare's Important Message.
  • Attends multidisciplinary rounds to ensure timely communication with the team.
  • Receives referrals for appropriate placement (NH, SNF, Assisted Living, LTAC, Acute Rehab, etc.) from Case Manager or Care Coordinator.
  • Reviews patient information from the electronic record and interviews patient and/or family for preference of facilities.
  • Completes DMA 6 where required and obtains appropriate signatures.
  • Updates any changes in insurance, demographic information, patient level of care, etc.
  • Ensures appropriate discharge documentation is available to accompany patient to the facility.
  • Stays in touch with the team, patient and family regarding post acute plans.
  • Coordinates appropriate transportation.
  • Assists with the application process for indigent medications working specifically with indigent programs and pharmacy assistance programs.
  • Continuously seeks new community resources and keeps team informed.
  • Provides therapeutic support for patients and families by listening to verbal communications and observing non-verbal behaviors.
  • Facilitates support groups as needed.
  • Provides support to the case managers for difficult discharge placements and for immigrants that require placement outside the USA.
  • Encouraged to participate on community-based committees and hospital committees related to post acute care services.
  • Responds to calls/referrals/consults within 24 hours.
  • Completes all documentation related to actions taken.
  • Performs clinical duties in accordance to NASW Code of Ethics.
  • Works all scheduled shifts, including weekend rotation, remote coverage and on-call schedule.
  • Masters Degree in Social Work from an accredited School of Social Work.
  • One (1) year experience in a hospital preferred, agency or institution providing related health care services.
  • CCM (Case Management Certification) or ACM (American Case Management Certification) preferred.
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